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Behavioral Dynamicssss > Lecture 11 - mood disorders part 1 (Billie) incomplete > Flashcards

Lecture 11 - mood disorders part 1 (Billie) incomplete Flashcards

1
Q

what regulates mood?

A

neurotransmitters in the brain, mostly serotonin, norepinephrine, and dopamine.

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2
Q

What are the depressive disorders

A

Major depressive disorder (MDD)
Dysthymia/persistent depressive disorder
Seasonal affective disorder
Premenstrual dysphoric disorder
Disruptive mood dysregulation disorder

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3
Q

What are the Bipolar disorders

A

Bipolar 1 disorder
Bipolar 2 disorder
Cyclothymia

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4
Q

What are the two most widely recognized systems used for psychiatric dianosis, billing, and coding

A

Diagnostic and Statistical Manual of mental disorders (DSM)
International Statistical Classifications of Diseases and Related Health problems (ICD)

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5
Q

For all psychiatric conditions, the DSM endorses a criteria based diagnostic approach requiring 3 conditions. What are they?

A
  1. the condition is NOT caused by direct effects of any drug or external exposure.
  2. the psychiatric disorder is not caused by effects of a medical condition
  3. there is SIGNIFICANT impairment of social functioning, occupational functioning, or both.
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6
Q

What is the lifetime prevalence of MDD? what about prevalence in the past 12 months?

A

21%
10%

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7
Q

What is the most common demographic affected by MDD
age
gender
race
socioeconomics

A

MC in younger populations (average age of onset = 30) and 2-3x more common in women.
Highest prevalence in native americans
Lower in asians/pacific islanders.
higher prevalence in low socioeconomic status

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8
Q

What are the genetic/biological factors that could be risk factors for MDD

A

Neurotransmitter expression/sensitivity
Response to antidepressant drugs
FH of depression or alcoholism

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9
Q

What are the life events factors that could be risk factors for MDD

A

adversity or loss of loved one, job, or relationship
early childhood trauma
postpartum period

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10
Q

What are the Medication factors that could be risk factors for MDD

A

glucocorticoids
interferons

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11
Q

What are the personality factors that could be risk factors for MDD

A

low self-esteem
sensitive to stressors
insecure or worried
dependent or unassertive
introverted

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12
Q

What are the social factors that could be risk factors for MDD

A

lack of close relationships
close individuals with depression
maladaptive learned behaviors from close individuals

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13
Q

What are the medical condition factors that could be risk factors for MDD

A

neurologic, infectious, cardia, endocrine (thyroid/adrenal), cancer, inflammatory

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14
Q

What is the diagnostic criteria for MDD

A

a depressed mood or anhedonia for equal to or more than 2 weeks AND one of the following:

SIG E CAPS

Sleep disturbance
Interest decreased
Guilt and/or feelings or worthlessness

Energy decreased

Concentration Problems
Appetite/ Weight Loss
Psychomotor Agitation or retardation
Suicidal Ideation

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15
Q

What are the MDD subtypes

A

Anxiety
catatonic
mixed
psychotic
atypical
melancholic
peripartum
seasonal

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16
Q

What is the Anxiety Subtype of MDD

A

High levels of accompanying anxiety in MDD

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17
Q

What is the catatonic Subtype of MDD

A

major psychomotor disturbances (lazy cat)

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18
Q

What is the Mixed Subtype of MDD

A

symptoms of mania accompanying MDD (insomnia, racing thoughts, increased energy)

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19
Q

What is the psychotic Subtype of MDD

A

MDD with accompanying psychosis (hallucinations and/or delusions)

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20
Q

What is the Atypical Subtype of MDD

A

MDD with reactivity to pleasurable stimuli, hyperphagia (insatiable hunger), hypersomnia (insatiable fatigue)

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21
Q

What is the melancholic Subtype of MDD

A

MDD with anhedonia, psychomotor changes, insomnia with decreased appetite.

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22
Q

What is the peripartum Subtype of MDD

A

MDD during pregnancy or within 4 weeks of birth

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23
Q

What is the seasonal Subtype of MDD

A

MDD associated with a particular season

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24
Q

To have MDD a patient must have

A

at least one major depressive episode SIG E CAPS for more than 2 weeks

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25
What is the timeline of depressive episodes
develop over days to weeks and can take about 20 weeks to resolve.
26
when is the highest risk of recurrence for MDD?
within the first few months following episodes resolution
27
what are the three ways that the course of MDD can vary among patients
1. single major depressive episode that resolves 2. multiple episodes with few to no s/s between episodes 3. persistent, fluctuating depressive s/s with no clear "remission"
28
What are the rates of recurrence for MDD
1 year = 40% lifetime = 85%
29
What is the Two-Question Screen (PHQ-2)
Quick initial screening for depression that asks for 2 key symptoms of a depressive episode. (depressed mood and anhedonia) NOT a stand alone test, needs follow up if positive!
30
What is the Patient Health Questionnaire-9 (PHQ-9)
Further evaluates presence and severity of depression can be used for initial screening or follow up evaluation
31
What is the Zung Self-Related Depression Scale
Allow a more in-depth rating of current depressive symptoms
32
What are the non-pharmacological treatment options for MDD
Psychotherapy Electroconvulsive Therapy (ECT) Vagal Nerve Stimulation Transcranial Magnetic Stimulation (TMS)
33
What are the pharmacological categories for treatment options of MDD
Supplements Herbals Antidepressants
34
What are the treatment goals when treating MDD
Provide thorough education maintain patient safety achieve full remission of symptoms Return patient to baseline functioning
35
What is the preferred approach to treating MDD
Combination of pharmacotherapy AND pyschotherapy
36
Criteria for mild/moderate depression that is treated outpatient
no suicidal/homicidal ideation or behavior no psychotic features minimal to no aggressiveness intact judgement able to perform basic ADL and maintain adequate nutritional/hydration status
37
criteria for severe depression that is treated inpatient
Suicidal/homicidal ideation or behavior with a specific plan or intent psychosis catatonia impaired judgement that puts patient/others at risk Grossly impaired functioning affecting ability to care for self.
38
what is psychotherapy
AKA "counseling" Cognitive behavioral Therapy (CBT) or Interpersonal Psychotherapy are most commonly used.
39
What is behavioral activation?
Restarting activities that ceased due to depression
40
what is the recommended type and amount of exercise to use as non pharmacologic treatment?
aerobic or resistance 3-5x/week, 45-60 minutes each session
41
what is Electroconvulsive therapy
Use of a small electric current to induce a cerebral seizure while patient is under general anesthesia
42
what are the indications for Electroconvulsive therapy?
patients with severe, refractory depression 1st line in patients with: severe suicidality severe psychosis catatonia malnutrition d/t food refusal secondary to depressive illness or if patient cannot tolerate any other therapies.
43
What is the most efficacious treatment for MDD
electroconvulsive therapy
44
what are the CI for ECT
no absolute Ci use with caution in patients with cardiopulmonary disease, neurologic disease or those on anticoagulants
45
what are the side effects of ECT
overall considered safe. MC adverse events are - cardiopulmonary, HA, nausea, transient cognitive impairment (brainfog), muscle aches
46
what is vagal nerve stimulation as a treatment for MDD
a device is implanted in the chest wall and connected to one (left) vagus nerve. may be helpful for refractory depression but recent studies show questionable efficacy
47
Describe the process of transcranial magnetic stimulation as a treatment for MDD
metal coil with magnetic field is placed against scalp to induce depolarization of neurons in a focal area. this is performed WITHOUT sedation or anesthesia and has NO intentional seizure induction.
48
what are the indications for TMS
treatment for refractory depression
49
what are CI for TMS
high seizure risk, incompatible implants (metallic, electrical, cochlear because of magnet)
50
what are the SE of TMS
seizures, HA, scalp pain, transient hearing loss
51
What are the three main supplements used in the treatment of MDD
S-Adenosylmethionine (SAMe) 5-Hydroxytryptophan (5-HTP) Omega-3 fatty acids
52
what is SAMe and how does it work
a supplement that already naturally occurs in the body. May raise dopamine levels
53
What is a group that SAMe may be helpful in
can be used as an adjunctive option for mild to moderate depression in pregnant patients
54
what is the SE of SAMe
may trigger manic episodes
55
what is 5-HTP
natural precursor to serotonin
56
what are the SE of 5-HTP
GI upset, serotonin syndrome, eosinophilic myalgia syndrome
57
How are omega 3 fatty acids used in MDD
may work better when combined with antidepressants
58
what is the SE of omega 3 fatty acids
may increase risk of bleeding
59
what are the herbal treatment options for MDD
st johns wort saffron ginkgo biloba
60
What does St johns wart do
increases serotonin and possibly NE and dopamine levels
61
what are the SE of St Johns wort
Risk of GI upset, serotonin syndrome, photosensitivity NUMEROUS DRUG INTERACTIONS (DDIs)
62
what is Safron
a herbal that may help with depression; MOA unclear
63
what are the SE of saffron
GI upset mania bleeding can be FATAL at high doses
64
what does Ginkgo Biloba do
causes improved mood in patients being treated for memory loss; may increase sensitivity to serotonin
65
what are the SE of Ginkgo Biloba
may increase risk of bleeding
66
how long should you take to titrate someone onto an antidepressant
7-10 days if not longer. START LOW GO SLOW
67
how long should you wait to see the full benefit of oral antidepressents
should do a trial of at least 4 weeks patients could see improvement as early as week 1 but it generally takes 4-6 weeks to see a response.
68
when should you consider treatment modification in oral antidepressants
if <25% improvement in baseline s/s after 4-6 weeks of using medication.
69
How long should oral antidepressants be continued?
6+ months after s/s improvement
70
What are the first generation antidepressants
Monoamine Oxidase inhibitors (MAOIs) Tricyclic Antidepressants (TCAs) tetracyclic Antidepressants (TeCAs)
71
what are the second generation antidepressants
Selective Serotonin Reuptake inhibitors (SSRIs) Serotonin-Norepinephrine reuptake inhibitors (SNRIs) Atypical Antidepressants Serotonin Modulators Ketamine/Esketamine
72
What is the most common class of antidepressants used for MDD
Second generation Antidepressants
73
what is the 1st line pharmacological treatment for MDD
SSRIs
74
what is the MOA for SSRIs
selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse.
75
what are the drugs in the SSRI class?
Fluvoxamine Fluoxetine Sertraline Citalopram Escitalopram Paroxetine FF SCEP
76
What is the dosing for SSRIs
usually given in the morning but doses can be split if SE are burdensome start low and go slow!!!
77
How are SSRIs metabolized
mostly hepatically so use caution in hepatic impairment
78
What are CI for SSRIs
allergy to SSRI Use of MAOI within 2 weeks FLUOXETINE = wait 5 weeks for MAOI!!!
79
what are SE of SSRIs
GI upset sleep change HA, dizziness decreased libido, anorgasmia, ED increase anxiety and risk of suicide prolonged QT, weight gain, bleeding Orthostatic Hypotension SEROTONIN SYNDROME
80
what SE of SSRIs are more common in adolescents and early 20s
risk of suicide and serotonin syndrome
81
what is serotonin syndrome
caused by increased serotonergic activity typically occurs within 24 hours (often within 6 hours) of starting/changing medications or overdosing.
82
what are s/s of serotonin syndrome
diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, DEATH.
83
how do you diagnose Serotonin syndrome
clinically 5-HT levels DO NOT correspond
84
what is the treatment for serotonin syndrome
supportive care D/C serotonergic medications sedation with benzodiazepines normalize vitals and hydration status
85
What are the specific side effects of sertraline
More GI upset, Esp diarrhea Less likely QT prolongation and drowsiness slightly higher chance of insomnia
86
what are the specific side effects of citalopram/escitalopram
most associated with Prolonged QT Minimal SE otherwise LEAST INHIBITION OF HEPATIC ENZYMES
87
what are the specific side effects of fluvoxamine
frequently causes somnolence DDIs SHORTEST HALF LIFE 15 hrs
88
what are the specific side effects of fluoxetine
LONGEST half life (up to 3 days) slightly higher risk of insomnia DO NOT USE w Tamoxifen
89
What are the specific side effects of paroxetine
Only one that causes anticholinergic SE slightly higher risk of hypotension, weight gain, and sexual dysfunction than others SHOULD NOT BE USED w Tamoxifen

Behavioral Dynamicssss (21 decks)

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